Healthcare Provider Details

I. General information

NPI: 1285348441
Provider Name (Legal Business Name): MICHAEL MCLANE MATTHEWS CCMA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 02/18/2023
Certification Date: 02/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 E 17TH ST
SANTA ANA CA
92705-6852
US

IV. Provider business mailing address

1333 S MAYFLOWER AVE STE 220
MONROVIA CA
91016-5239
US

V. Phone/Fax

Practice location:
  • Phone: 714-547-5375
  • Fax:
Mailing address:
  • Phone: 512-661-8103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberT7A7N8C3
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: